Grievance and Appeals BH Nurse - Remote | WFH
We are seeking a compassionate and detail-oriented individual to join our team as a Grievance and Appeals Coordinator. In this role, you will play a vital part in ensuring the fair resolution of complex grievances and appeals requests from both our valued members and providers.
Key Responsibilities...
Conduct thorough investigations and reviews of grievances and appeals, particularly focusing on cases of medical necessity.
Evaluate prospective, inpatient, or retrospective medical records for denied services, extracting and summarizing pertinent medical information for review by medical directors and external consultants.
Prepare well-founded recommendations regarding the approval or denial of appeals, forwarding them to the Medical Director for final approval.
Uphold regulatory timeframes by ensuring timely resolution of appeals and grievances.
Accurately document and log all appeal and grievance information using our tracking and mainframe systems.
Craft clear and professional written correspondence to providers, members, and regulatory bodies.
Demonstrate leadership by serving as a subject matter expert on appeals, grievances, and quality of care issues, providing guidance and support to both clinical and non-clinical team members.
Requirements
Minimum of 2 years of experience in a managed care healthcare setting, or an equivalent combination of education and experience.
Previous Experience In Behavioral Health Is Preferred.
Hold a current, active, and unrestricted RN license to practice within the scope of licensure in [insert state abbreviation].
Possess strong oral, written, and interpersonal communication skills, as well as exceptional problem-solving, facilitation, and analytical abilities.
Preferred certifications include MCG (Milliman Care Guidelines) and CMCN (Certified Managed Care Nurse).
A Bachelor's or Associate's degree in Nursing is preferred.
We are committed to fostering a supportive and inclusive work environment where every team member can thrive. If you are passionate about making a positive impact in healthcare and possess the necessary skills and qualifications, we encourage you to apply. Join us in our mission to deliver high-quality care and support to our members and providers.
Employment Type: Full-Time
Similar Remote Jobs
Grievance and Appeals BH Nurse - Remote | WFH
Posted on: 16-07-2024 18:53
American Express Data Entry Jobs (Live Chat, Remote) $35/Hour 2024...
Posted on: 16-07-2024 18:53
American Express Live Chat Support Job (Remote/Virtual) ? MySmartPros
Posted on: 16-07-2024 18:53
Part Time American Express Jobs @privatejobspune ( Customer Care...
Posted on: 16-07-2024 18:53
American Express Remote (No Degree) - Work From Home
Posted on: 16-07-2024 18:53
American Express Virtual Assistant Jobs $25/Hour
Posted on: 16-07-2024 18:53
American express Remote jobs (Data Entry)
Posted on: 16-07-2024 18:53
American Airlines Customer Service Remote job (Work From Home)
Posted on: 16-07-2024 18:53
American Airlines Remote Customer Service $21 An Hour
Posted on: 16-07-2024 18:53
American Airlines Remote Jobs (Part Time, Full Time) ? DPS
Posted on: 16-07-2024 18:53
Claims Call Center Representative - American Express
Posted on: 25-09-2024 00:00
Technical Support Engineer, Amazon Robotics Technical Support (ARTS)
Posted on: 14-02-2025 07:18
Virtual Data Entry – $16/Hour Work From Home
Posted on: 12-09-2024 00:00
Remote Entry-Level Client Data Entry Clerk (Typist)
Posted on: 07-11-2024 05:43
Luxury Travel Consultant - Flexible Hours & Full Training Provided
Posted on: 15-09-2024 00:00
Remote Insurance Sales Agent
Posted on: 26-08-2024 00:00
Home-Based Customer Service Reps - Chat Support | $25-$35/hr | Entry-Level
Posted on: 02-09-2024 00:00
Conversion Tracking (Calendly - Google Analytics/GTM/ Google Ads)
Posted on: 29-08-2024 00:00
Amazon Delivery Driver
Posted on: 23-11-2024 06:30
CDL Class A Driver
Posted on: 14-02-2025 07:17